ANNEXT'RT - 3

Appltcatlon for Deceased Clalm

I ro beusedwhen.rr'"".;lhl:ljt1.::i or rsaJotntaccountwlth
From:

To
The Branch Manager
Uttarbanga Kshetriya Gramin Bank
Branch

Dear Sir,
Reg : Deceased Account
[.ate Shri/Smt,
Account No[s]

I/We advised, the demise of Shri/Smt on

. He/She holds the above account[s] at your . The account is in

the name{s} of

A. In case of ltomlnatlon
I Son/daugfrter of Shri
residing at

li1 the registered nominee in the above account[s]

iiit the person authorized to receive pa5rment on behalf of Master/Miss
who is the
nomlnee in the above account[s] and is a minor as on the date of the claim.
Please settle the balance in the account in the natne of the'nominee . I/We receive the
payment as trustee[s] of the legal heirs of the deceased..

B. IN THE CAST OF JOINT ACCOUNT :

I/We request you to delete the name of deceased person and continue the account in
my/our name[s] with same mode of operations.

I/We submit photocopy of the following documents together with originals. Please
return the original to us after verification' .

Death Certificate issued by

Identity proof [required in nomination cases] :

Yours faithfully,
Date:
Place: ClaimantIs]

34
 ANNEXT'RE - 4

Application for Deceased Claim

I To be used for cases other than nomination/Jotnt account wlth Survivor clause]

From :

To
The Branch Manager
Uttarbanga Kshetriya Gramin Bank
Branch

Dear Sir,
Reg:: Deeeased Account
Late Shrt/Smt.
Account No [s]

I/We advise , the demise of Shri/Smt.

He/She holds the above account[sl at your Branch. The account is ln the
name[s] of

I/We lodge mylour claim for the balances with accrued interest lytng to the credlt of
the above named deceased who died intestate. I/We am/are the Ggai heirs of the
above named deceased and lodge my/our claim for pa5zment as per the bank's rules
and dlscretion. The relevant information about the deceased and the legal heirs are as
under:

1. Names in full of the parents of the deceased:

Father

Mother

2. Religion of the deceased :

3. Details of livlng [i] Husband [iil wife [iii] children [ivl Father [v] mother
ffi Brother [vii] sisters [viii] Grand children. If Hindu Joint Family, the
Name and address of the lkrta and Co-parceRerswlth their respective ages.

Full Name/Address Occupation Relationship with Age

Deceased.
1.
2.
3.
4.
5.
6.

35
l4l Name or names of the Guardlan/s
of the Mlnor, Chlldren of the Depositors;

Ial Whether Natural Guardian

tbl Whether Guardlan appotnted by

Gourt of Law ln India. If so,
Attach a Certlfied copy or duly
Attested copy of such order

[c] In whose custody the

Mtnor/Minore is/are

t5l Clatmant/s name/s and address ln full

I{
IiTI
tfirl
I/We submlt the followlng documeats. Please return the orlglnal death certlflcate to
us after verlflcation.

IU Death Certlflcate I Orlglnal + 1 Photocopyl lssued by

121 Letter of lndemnttY

We request you to pay tle balance amount b'tag to the credlt of the above naned
deceased to on mY/our behalf.

I/We hereby solemnly atrrm that tle above statements are tnre and correct to the
best of my/our knowledge and bellef.

Place : Yours fatthfully

Date : Slgnature of Clalmant[s]

NAME OT CLAIMANT ADDRESS SIGNATURE

36
 ANNE:rI'RE - 5

AFFIDAVIT CUM INDEMNTTTLErfER

In respect of payment of balance in Deposit Accounts/contents of Safe Deposit

Locker / Safe Custody articles of deceasedperson ;

ITo be stamped with the duff payable for affidavit & Indemnity bondl

I / W e M r / M s / Mi ss

[name/names of the claimants],

ls/o,w/o, D/o l,
aged,

address,

do hereby solemnly affirm and state as follows.

t1l I/We arnf arethe legal heirs of Mr/Ms/Miss I Name of the deceasedaccount
holder I and the deceased is my/our
[father / mother/ wife / hu sband / son/ dau ghter etc.],

l2l I/We further state that I/We the following legal heirs are the only legal heirs
entitled to claim the balance deposit/amount/jewels/ornaments and other
valuables the contents held in the locker/safe custody:-

N o . Name Age Relationship to the deceased

I
2
3
4
5

t3l I/We further state that the deceased was holding an account [hereinafter
referred to as "the account"] [specify the account details]
Branch of
Bank [herein after
referred to as "the Bank"l . At the time of death of the deceased the account
was having a credit of Rs. I balance amount in the
accountl which includes interest upto I date of payment]
amount to Rs. [amount being now paid]

37
t4l I/We affirm that I/We artf are the sole legal heirs of the deceased who are
entitled to receive the amount standing in the credit of the account belonging
to the deceased.

tsl I/We have requested the Bank to make the payment of the amount standing
in the credit of the account belonging to the deceased together with interest
thereon as applicable to Shri/Smt. being
one of the legal heirs for and on behalf of all the legal heirs.

OR

I/We have requested the Bank to hand-over contents of the Safe deposit
locker/items held in safe custody to Shri/Smt.
being one of tlle legal heirs for and on behalf of all the legal heirs.

t6l I/We are aware that the Bank has agreed to settle our claims relying on this
affidavit and I/We agree to indemmfy the Bank in respect of such pa5rment or
delivery of the contents of items in Safe Deposit Locker or held in Safe custody
against any claim made by any person for the amount standing to the credit
ofth. account of the deceased

17l I/We for ourselves and my/our respective heirs, executors and administrators
jointly and severally agree, alfrrm and undertake that the Bank, its successors
and assigns and its managers, agents, Officers and servants and their
respective estates and effects are and shall from time to time and at all times
hereafter be kept safe and saved harmless and indemnified for and in respect
of such pa5rment and against all actions, losses, cost, charges, expenses and
demands whatsoever in respect of the said payment or delivery of the contents
of times in safe deposit locker or held in safe custody.,

A11the averments made herein before are true and correct and I/We put my/our
signature/mark on this day of 200
at 1n the presence of

SrGr{ATUREISIOF DEPOIYENTS.I CLAIMANTSI

SIGNATUREOF WITNESS :

Affidavit to be attested by Notary hrblic :

38
 ANNEXURE.6

RECEIPT

Receive with thanks from Uttarb4nga Kshetriya Gramin Bank,

Branch , a sum of Rs.
IRupees onlyl by
Banker's Cheque No. dated in
favour of
final settlement of my/our claim as successor on the balance in
Account[s] No[s] standing in
the name of the deceased Shri/Smt./Kum.
I/We do not have any other claim from the
Bank henceforth.

Place
Date

ISIGNATUREOF ALL THE I.EGAL

HEIRSOVERA REVENUE STAMP]

Declaration in case funds are settled in favour of a Minor.

I, father and natural gu ardian of

hereby certify that the proceeds of your Banker's
Cheque No. dated favouring
issued by you in settlement
of the balance in account nurnber
of Late will be utilized for the benefit of
the minor only.

39
 ANNEXT'RT -7

Form of Inventory of Contents of

Safetv Locker Hlred from Banklns Comrranv
[Section 46ZZD14I of the Banking Regulatlon Act, t9491
[To be used where there is nomlnation or survlvorshtp clausel

The following inventory of contents of Safety Locker No. located in

the Safe Deposit Vault of Branch at

o hired by Shri/Smt. [deceased] in his/her

sole name.
o hired by Shri/Smt. lil Ideceased]

liil ointlY

tiiil
was taken on this

Description of Articles in Safety Lockg:1

pot ttte pqrpose of inventory acrcessto the locker was given to the Nominee/and
surviving hirers.
. By breaking open the locker under his/her their instmctions.
. Who prod.uced the key to the locker [delete whichever is not applicable]

The above inventory was taken in tJle presence of :

[1] Shri/Smt. INominee]

Address I Signature ]

Shri/Smt. INominee]

Address I Signature ]
and
Sri/Smt.
Survivors of I Signature ]
Joint hirers

Address

Shri/Smt.

Address I Signature ]

t2l Witness[es]with name, address and signature :

40
 o I, Shri / Smt. Nominee]

n We, Shri/Smt. INominee]

Shri/Smt
the survivors of the joint hirers, hereby acknowledge the receipt of the contents of
the safety locker comprised in and set out in the above inventory together with a
copy of the said inventory.

Shri/Smt. INominee] Shri/Smt.

Signature Signature

Date & Place

ISurvivor] Shri/Smt.

Signature

Date & Place

NOTE:
It is made clear that access to locker is given to survivor[s]/nominee[s] only as a
trustee of the legal heirs of the deceased locker hirer on the condilion that such
access if given to suryivor[s] / nominee[s] shall not affect the right or claim which
any person may have against the survivor[s] / nominee[s] to whom the access is
glven.

4l
 AItNEx{tRE - 7[al
Form of Inventory of Contents of
Safety Locker Hired from Banking Company
or survivorship clause]
[To be used where there is no nomination
located in
rf The following inventory of contents of Safety Locker No'
of Branch at
the Safe Deposit Vault
a
hired by Shri/Smt. [deceased] in his/her
sole name.
hired by Shri/Smt. [i]
Ideceased]
tiil
tiiil
was taken on this day of 20

Description of Articles 14 te&El,ocker

ForthepurpoSeofinventory,acffigrventothe1egalheir[s]/a
person maniated by the legal heir[s] and surviving hirers.
. By breaking open the locker under his/her/ their instructions'
o Who produced the key to the locker [delete whichever is not applicable]

The above inventory was taken in ttre presence of :

[1] Shri/Smt.
ISignature]
Address

la Shri/Smt.
ISignature]
,ch
Address
ich and
Sri/Smt.
is ISignature]
Survivors of
Joint hirers

Address

Shri/Smt.
I Signature ]
.Address

l2l Witness[es] with name' address and signature :

-11 42
 Shri/Smt.
Signature

Address :

Shri/Smt.
Signature
Address

ACKITOWLEDGEMEIVT

. I , Shri/Smt. legal heir/mandate holder

I W€, Shri/Smt.

legal heirs and

Shri/Smt.

Surviving hirers

Hereby acknowledge the receipt of the contents of the safety locker comprised in ad
set out in the above inventory together with a copy of the said inventory.

Shri/Smt.
I Legal Heir/Mandate Holder ]

Shri/Smt. Signature

Shri/Srnt. Signature

Shri/Smt. Signature

Date & Place

[* Delete whichever is not applicable]

43
 AITITEXT'R8.8
Forur of Inventory of artlcles left ln
Safe Custody wtth Banklng Company
[Sectton 45?fr131of the Banklng Regulatlon Act, 19491
Fo b. used where there ls nomlnatlon of Survlvorshtp clausel

The following inventory of articles left in Safe custody

with Branch , bY Shri/Smt.
[deceasedlunder an agreernent/receipt dated
Was taken on this, day of -2o

Sr. No. Description of Articles in Safe custody Other identifying particulars, if

anv.

The above inventory was taken in the presence of :

tu Shri/Smt. Nomineel

Shri/Smt.

[Appointed on behalf of Minor Nomineel

Address :

Address:

Signature

Signature
d
I, Shri/Smt. [Nominee/appointed on behalf of
Minor Nomineel hereby acknowledge receipt of the articles comprised and set out in
the above Inventory together with a copy of the said inventory.

Shri/Smt

Signatgure

Date & Place

Shri/Smt.

I Appointed on behalf of minor Nominee]

Signature

Date & Place

43 44
Note :

It is made clear that access to safe custody articles is - given . to

survivor[s].nominee[sl onty'as a Trustee of the legal heirs of t]re deceased depositor
-articlis
of Safe Custody on the condition that such access if given to
survivor[sl/nominee[s] shall not alfect the right or claim which any person may have
against ttre survivor[sl / nominee[s] to whom the access is given.

..:
.L
IT

:$i
*
"i
.l

': 3;
.:l* .
,ik-:
.51
'. '.: #
3
,
' ''i{l '
:€*
_:lo

s* i

45
 ANIIE.KIIRE - 8[al
Form of Inrrentoty of articles left ln
Safe Custody with Banklng ComPanY
I To bc ured rhere there ls no nominatlon or survlvorshlp clause]

The following inventory of articles left in Safe custody

with Branch, by Shri/Smt. Ideceasedl
under on agreementf receipt dated was taken on this, day of
2A_.
Sr. No. Descriotion of Articles in Safetv Locker Other identifying particulars, if any.

The above inventory was taken in tl e presence of,

Legal heirs or a person mandated by legat heirs

[1] Shri/Srnt.
I Signature]
Addresss :

[2] Shri/Smt.
I Signature ]
Address

ACIIITOWLEDGEMENT
* I Shrt/Snt. legal helr/mandate holder

o We , Shri /Smt.

legal heirs and

Shri/Smt.

surviving hirers

Hereby acknowledge the receipt of the articles cornprised and set out in the above
inventory together with a copy of the said Inventory.

Shri /Smt.
[Legaf Heir/ Mandate Holder]

Shri/Smt. Signature

Shri/Smt. Signature

Shri/Smt. Signature

Date & Place

[* Delete whichever is not applicabie]

46
Legal heirs under various personal laws : AITNEXT'RE - 9
Iil HrNDU:
[al Prlmary heirs of a Hlndu male are :
i. Son[s]
ii. Daughter[s]
iii. Wife
iv. Mother
v. Children of predeceased Children
vi. Widow of predeceased son
vii. Children of predeceased grand children

Ibt Hmary hetr[sJ of a Hlndu fenale are :

i. Son[s]
ii. Daughter[sJ
iii. Husband
iv. Childrenofpfedeceased:children

liil MusLrMs

ii. Daughter[s]
iii. Father
iv. Mother
v. Spouse [Husband/Wfe]

tbr l"-'3o|;S'i*f#i,Hfffare:
ii. Mother
iii. Father
iv. Son[s]
. Daughter[s]

lff{ Chrtstlans:
lal Prlmary helrs of a Ghrlstlan arre: I
i. Spouse[Husband/Wife]
ii. Son[s]
iii. Daughter[s]

livl Parsis:
[al Hrnary helrs of a Parsl male are :
i. Wife [widow]
ii. Son[s]
iii. Daughter[sJ
iv. Mother
v. Father
vi. Children of PredeceasedChildren

tbl Prlmary helrs of a Parsl fernale are :

i. Husband
ii. Son[s]
iii. Daughter[s]
iv. Children of PredeceasedChildren

47
 AtrITEKTIRT- 10
ITo be stamped as per t]re Stamp act applicable to the Statel
DECALRATION ON OATH

We,Shri/Smt. residing at
do hereby solemnly affirm and state as
unden

[1] That Shri/Smt. the husband/wife of

Iname of t]re deceasedl
the above named deponent Shri/Smt and the
father / mother of the above named
deponents , died intestate at

[2] That he / she left behind him/her surviving the following persons as his / her
only heirs according to the I,aw of Intestate Succession' applicable to
by which Law he /she was governed at
( Hindu , Muslim , Parsi etc.,l
the time of his/ her death.

S1 Name of the Heir Address Age Occupation Relationship

No. with the
deceased
a
b
c
d
e

[3] That the said Ihereinafter

unless expressly named or otherwise distinguished for brevity's sake called the
deceased ] maintained Account No.
with Uttarbanga Kshetriya Gramin Bank at its Branch
in his I her name.

[af That no letters of representation to his / lnerestate have been obtained or are
contemplated to be obtained.

[5] That Rs. is the amount due and payable to the

deceased by Uttarb€rnga Kshetriya Gramin Bank being the balance to the credit of
the aforesaid account.

[6] That the decee.sedhas not left any debts and no amount is due to Uttarbanga
Kshetriya Gramin Bank from his /her and that in the circumstances mentioned
above , the abovenamed deponents are the only persons entitled to the amount
standing to the credit of the aforesaid account and no
other person is entitled thereto or to any part thereof.
48
I
l
I [7JWe hereby further state that,we kno-wthat relying on the above representations
I
tr
and believing the sgme-to.be tru9 Uttarbanga Kshetiya Gramin eank has agreed to
pay the aforesaid sum beinq tlt" balance stanaing to the credit of the '
I
ll ,
Accounttotheabovenameddeponents.,.withotr|insistingonp'oa,'"uli@
ll
representations, l
]
ll
tr

II
l

1.

2.
i
I 2
v.

( Sigpture / thurnb irnpression of the deponent )

Solemnly affirmed by the

Above named deponent at
On the day of
20 in the presence of

49